Blue Cross Medicare Advantage Dental Premier (PPO) 2024 Benefit Details for Plan H1666-016-0 in Mora County, NM
Blue Cross Medicare Advantage Dental Premier is a 2024 PPO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This Blue Cross and Blue Shield of NM, TX option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
See more Medicare Advantage Plans in Mora County, New Mexico.
Plan Basics | |
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Plan ID: | H1666 016 0 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $7,550/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $545.00 deductible |
Rx Gap Coverage: | No |
Supplemental Benefits: | Dental, Vision, Hearing |
Availability: | Mora County, NM |
Insured By: | Blue Cross and Blue Shield of NM, TX |
Summary of Benefits |
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Health Plan Cost Sharing
This Blue Cross and Blue Shield of NM, TX Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $45 Copay Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $40 Copay Authorization Required |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $15 Copay Authorization Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $100 Copay |
Urgent care: | $40 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $370.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient hospital coverage: | $300 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 through 59 $0.00 per day for days 60 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $40 Copay |
Outpatient group therapy visit with a psychiatrist: | $40 Copay |
Inpatient hospital - psychiatric: | $290.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient group therapy visit: | $40 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $40 Copay Authorization Required |
Occupational therapy visit: | $40 Copay Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $300 Copay Authorization Required |
Lab services: | $50 Copay Authorization Required |
Outpatient x-rays: | $100 Copay Authorization Required |
Diagnostic tests and procedures: | $100 Copay Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Blue Cross Medicare Advantage Dental Premier Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Blue Cross and Blue Shield of NM, TX includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | Maximum dental benefit: | Non Specified |
Oral exam (In-Network) | Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Covered |
Cleaning (In-Network) | Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Covered |
Non-routine services (In-Network) | Covered |
Diagnostic services (In-Network) | Covered |
Extractions (In-Network) | Covered |
Endodontics (In-Network) | Covered |
Restorative services (In-Network) | Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay |
Vision | Maximum vision benefit: | $100.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Blue Cross Medicare Advantage Dental Premier includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $0.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $0.00 |
Part D Premium with Full LIS Assistance: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $545.00. This is the amount you must pay at the pharmacy before Blue Cross and Blue Shield of NM, TX begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Blue Cross Medicare Advantage Dental Premier has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $0.00 copay (deductible does not apply) | $15.00 copay (deductible does not apply) |
2 (Generic) | $8.00 copay | $20.00 copay |
3 (Preferred Brand) | $47.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay |
5 (Specialty Tier) | 25% | 25% |
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Blue Cross and Blue Shield of NM, TX plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent ratings for Blue Cross Medicare Advantage Dental Premier.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- Blue Cross Medicare Advantage Choice Premier
- Blue Cross Medicare Advantage Health Choice
- Blue Cross Medicare Advantage Dental Premier
- Blue Cross Medicare Advantage Saver Plus
- Blue Cross Medicare Advantage Flex Access
Contact Blue Cross and Blue Shield of NM, TX
Plan Website: | http://getbluetx.com/mapd |
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Formulary Information: | http://getbluetx.com/mapd/pharmacies |
Pharmacy Information: | Blue Cross and Blue Shield of NM, TX Pharmacy Page |
Prospective Members: | (877)583-8129 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Blue Cross and Blue Shield of NM, TX, http://getbluetx.com/mapd, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H1666-016-0 Plan Detail Page
The data on this Blue Cross Medicare Advantage Dental Premier plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Blue Cross and Blue Shield of NM, TX to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Blue Cross and Blue Shield of NM, TX, at (877)583-8129, prior to enrollment.